Housing Assistance Application

Transcription

1 Housing Assistance Application Head of Household Information Date: Last Name First Name: Middle: Note: Names should be legal names only, not aliases or nicknames Suffix (circle one) II III IV Jr Sr None Other If other suffix, please specify SSN - - Birthdate / / Age Phone Number(s) Current Address Street Number / PO Box City State Zip Gender (check one) Female Male Veteran Status Yes No Disabling Condition? Yes No Pending Don't Know (circle one) Hispanic/Latino Yes No Don't Know (circle one) Race (check all that apply) White American Indian/Alaskan Native Black/African-American Asian Native Hawaiian/Other Pacific Islander Zip Code of Last Permanent Residence Don't Know Housing Status (check one) Literally Homeless Imminently at-risk of becoming literally homeless Precariously housed and at risk of homelessness Stably housed

2 Have you been homeless more than once in the past 12 months? Yes No Where have you been staying primarily for the past month if homeless? Have you received an eviction notice? Yes No If yes, when? How much do you pay in rent per month? How much do you pay in utilities? How many bedrooms? Do you owe back rent? Yes No If yes, amount owed Prior Residence Type of Residence (check one) Emergency Shelter Transitional Housing for homeless persons (including homeless youth) Permanent housing for formerly homeless persons Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric) Jail, prison or juvenile detention facility Rental by client, no housing subsidy Owned by client, no housing subsidy Staying or living in a family member s room, apartment or house Staying or living in a friend s room, apartment or house Hotel or motel paid for without emergency shelter voucher Foster care home or foster care group home Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside); inclusive of nonhousing service site (outreach programs only) Other (Please specify ) Safe Haven Rental by client, with VASH housing subsidy Rental by client, with other (non-vash) housing subsidy Owned by client, with housing subsidy Length of Stay at Prior Residence (check one) One week or less More than one week, but less than one month One to three months More than three months, but less than one year One year or longer Have you experienced a recent and unexpected drop in income? Yes No If yes, please explain in detail:

3 Yes No Income and Sources Income received from any source in past 30 days? Yes No (circle one) If yes, fill out the following: Monthly Income Source Amount Earned Income (i.e., employment income) $ Unemployment Insurance $ Supplemental Security Income (SSI $ Social Security Disability Income (SSDI) $ Veteran's disability payment $ Private disability insurance $ Worker s compensation $ Temporary Assistance for Needy Families (TANF) $ Alimony or other spousal support $ Retirement income from Social Security $ Veteran s pension $ Pension from a former job $ Child support $ Other source $ Other source $ If other source, please specify Total average monthly income amount $ Non-Cash Benefits Non-cash benefit received from any source in past 30 days? Yes No Don't Know (circle one)

4 Yes No If yes, fill out the following: Monthly Benefit Source Amount Food stamps or money for food on a benefits card $ MEDICAID health insurance program $ MEDICARE health insurance program $ State Children s Health Insurance Program $ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) $ Veteran s Administration (VA) Medical Services $ TANF Child Care services $ TANF transportation services $ Other TANF-funded services $ Section 8, public housing, or other rental assistance $ Other source $ If other source, please specify Physical Disability Yes No Don't Know (circle one) If yes, currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) Developmental Disability Yes No Don't Know (circle one) If yes, currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) Chronic Health Condition Yes No Don't Know (circle one) If yes, currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) Mental Health Problem Yes No Don't Know (circle one) (If client has a mental health problem) expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Don't Know (circle one) (If client has a mental health problem) currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) Substance Abuse (check one) No

5 Alcohol abuse Drug abuse Both alcohol and drug abuse (If client has a substance abuse problem) expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No (circle one) (If client has a substance abuse problem) currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) HIV/AIDS Yes No (circle one) If yes, currently receiving services or treatment for this condition or received services/treatment prior to exiting the program? Yes No Don't Know (circle one) Domestic Violence Experience Yes No (circle one) If yes, when experience occurred (check one) Within the past three months Three to six months ago From six to twelve months ago More than a year ago Employment Employed Yes No (circle one) Number of hours currently working per week Tenure (check one) Permanent Temporary Seasonal If not working, looking for work Yes No (circle one) Adult Education (at least 18 years of age) Currently in school or working on a degree or certificate Yes No (circle one) Received vocational training or apprenticeship certificate Yes No (circle one) Highest level of school completed (check one) No schooling completed Nursery school to 4th grade 12th grade, no diploma High school diploma

6 5th or 6th grade 7th or 8th grade 9th grade 10th grade 11th grade GED Post-secondary school Don't Know Post-secondary Degrees (check all that apply) None Other graduate/professional degree Associates Certificate of advanced training or skilled artisan Bachelors Don't Know Masters Doctorate If other degree, please specify Child Education (between 5 and 17 years of age) Currently enrolled Yes No Don't Know (circle one) If yes, Name of School If enrolled, was/is the child connected to the McKinney-Vento Homeless Assistance Act school liaison? Yes No Don't Know (circle one) If enrolled, type of school (check one) Public school Parochial or other private school If not enrolled, last date of enrollment / / If not enrolled, identify problems with enrolling child (check all that apply) None Lack of available preschool programs Residency Requirements Immunization requirements Availability of school records Physical examination records Birth certificates Other Legal guardianship requirements Transportation If other, please specify

7 Military Information Military Service Eras (check all that apply) Persian Gulf Era (August 1991 Present) Post Vietnam (May 1975 July 1991) Vietnam Era (August 1964 April 1975) Between Korean and Vietnam War (February 1955 July 1964) Korean War (June 1950 January 1955) Between WWII and Korean War (August 1947 May 1950) World War II (September 1940 July 1947) Duration of Active Duty months Served in a war zone Yes No Don't Know (circle one) If yes, name of war zone (check all that apply) Europe Korea North Africa South Pacific Vietnam Persian Gulf Laos and Cambodia Other South China Sea China, Burma, India If Other war zone, please specify If yes, number of months in war zone months If yes, received hostile or friendly fire? Yes No (circle one) Branch of the military (check all that apply) Army Other Air Force Don't Know Navy Marines If Other branch, please specify Discharge status (check one) Honorable General Medical Bad conduct Dishonorable Other Don't Know If Other discharge status, please specify

8 General Health Status (check one) Excellent Poor Very good Good Fair Pregnancy Status Yes No Don't Know (circle one) If yes, due date / / Services Provided Type of Service (check one) Homeless prevention Housing placement Temporary housing and other financial aid Case / care management Household Information If you are the head of household, record the Names and Birthdates of ALL persons in your household. Name DOB SS # Sex Ethnicity Relationship To Head of Household

9 Certification of Accuracy I / We hereby certify that all information contained herein is true and accurate to the best of my knowledge. I /We understand that false statements or information are punishable under Federal Law. Customer Name Customer Name Customer Signature and Date Customer Signature and Date